Areas Of England Research Articles

JUE Insight: The labor market effects of place-based policies: Evidence from England’s Neighbourhood Renewal Fund

Neighbourhood renewal programs are a type of place-based policy that aim to revive underperforming localities. The literature on place-based policies has found mixed results regarding their effects on local labor market outcomes, but there are relatively few studies of policies that aim to improve local labor supply. In this paper we examine the labor market effects of the Neighbourhood Renewal Fund, which targeted 88 of the most deprived areas in England during the early 2000s as part of the Labour government’s National Strategy for Neighbourhood Renewal. The fund disbursed almost £3 billion for spending on community safety, education, healthcare and worklessness, with supply-side interventions making up the bulk of the program’s spending on worklessness. Using a difference-in-differences approach, we find statistically significant impacts on local employment. Our results suggest that policy interventions to improve local labor supply can be a successful strategy for neighborhood renewal.

Future patterns of health inequalities in the population of England to 2040: a microsimulation study

Abstract Introduction The existence of wide inequalities in health across England is well-documented. Our research adds to this evidence on inequalities in self-reported health by describing current patterns and projecting future patterns of inequality in diagnosed illness across multiple conditions by deprivation. Methods We used the IMPACTNCD microsimulation model that simulates a close-to-reality synthetic population of adults in England from 2019 to 2040. This model combines individual-level data on demographics, health and mortality from linked administrative data for primary and secondary care with survey responses on individual-level risk factors and epidemiological evidence on the associations between risk factors and chronic illness. This model can be adapted for other countries based on data availability. We used the Cambridge Multimorbidity Score (CMS) as our multimorbidity measure. This assigns a weight to 20 common long-term conditions based on individuals’ healthcare use and their likelihood of death. We further focus on “major illness” which corresponds to a CMS greater than 1.5. Results In preliminary results, we project that health inequalities are not projected to improve between 2019 and 2040. In 2019, the difference in the average time spent without major illness between the most and least deprived 10% of areas in England was 10.4 years. This is projected to remain largely unchanged at 10.7 years (8.8, 11.7). We also find that in 2019, the share of working age people living with major illness in the most deprived 10% of areas in England (14.6%) was more than double the rate seen in the least deprived 10% of areas (6.3%). In 2040, we project these rates to remain largely unchanged at 15.2% (13.0%, 17.6%) and 6.8% (5.4%, 9.1%) respectively. Discussion On current trends, health inequalities are projected to persist into the future. This has significant implications not just for population health but for labour supply and wider economic growth. Key messages • If current trends in risk factors continue into the future, existing wide inequalities in diagnosed illness in England are projected to persist onto 2040. • With significant disparities in major illness among the working-age population, this has implications not just for population health but for labour supply and wider economic growth.

The long-term effect of the coronavirus pandemic on parkrun participation: an interrupted time series analysis

BackgroundThe growth of parkrun between 2004 and 2019 has been heralded as a success story for public health as a result of its physical activity and wellbeing benefits for participants. However, parkrun was not immune from the COVID-19 pandemic - with events in mainland England cancelled from March 2020 to July 2021. This study explores the lasting impact of the pandemic on parkrun participation to February 2023, and its implications across the socioeconomic spectrum.MethodsThe study combines aggregated parkrun weekly finisher data from 32,470 Lower Layer Super Output Areas (LSOA) in England from January 2015 to February 2023 with Office of National Statistics (ONS) data on population and deprivation. Interrupted time series analysis using segmented Poisson regression models was used to estimate the immediate change in parkrun participation and the change in the rate of growth following the pandemic. Models were fitted for each Index of Multiple Deprivation (IMD) quintile separately to assess whether this effect differed by socioeconomic deprivation.ResultsVisualisation and interrupted time series analysis showed a significant and long-term decrease in parkrun participation following the reopening of parkrun events. This was consistent across all IMD quintiles, indicating that the inequalities in parkrun participation according to IMD observed prior to the pandemic remained after the pandemic. Between March 2020 and February 2023, almost 13 million fewer parkrun finishes are estimated to have occurred relative to what would have occurred in the absence of the pandemic.ConclusionThe reduction in parkrun participation during the pandemic and following the reopening of events is likely to have negatively impacted wellbeing in would-be participants. Going forwards, policymakers must make the difficult trade-off between the long-term health and social implications of restricting outdoor physical activity events against the benefits associated with a reduction in infectious disease transmission.

From marine plans to marine licences: a weak link in the English system?

ABSTRACT As marine spatial planning becomes established, attention is turning to the influence of plans on coastal and marine decisions. A study of marine licencing in the East Marine Plan Areas in England, UK, revealed that little reference is being made to plans. A technical approach to licencing has persisted despite the broader perspectives that spatial planning can offer. Also, plans may not be sufficiently specific and tested to guide licencing. Reforms to integrate planning and decision-making are needed, including plans designed to help with setting conditions and spatially allocating marine uses. Increased dialogue between planners and decision-makers is also needed.

Health optimisation for patients with obesity before elective orthopaedic surgery: a qualitative study of professionals’ views on restrictive approaches and future practice

BackgroundPreoperative health optimisation for elective surgery entails supporting patients to improve their health in preparation for their treatment and recovery. While there is consensus that this process should address obesity, approaches vary across England. Despite guidance from the National Institute for Health and Care Excellence to the contrary, restrictive approaches with body mass index thresholds for referral to arthroplasty are in use. This qualitative study aimed to investigate the views of professionals on the current use and future implications of these policies.MethodsSemi-structured interviews were conducted with 20 professionals including clinicians, commissioners, policymakers, and health service managers, with experience of developing and/or implementing health optimisation policies for elective arthroplasty. Participants were sampled from areas in England with and without restrictive policies. We undertook thematic analysis of the interview data.ResultsParticipants described pre-surgical health optimisation as an important trigger for health improvement but identified current resourcing and inadequacies in provision of weight management support as significant barriers to success. Participants expressed concerns about the appropriateness and fairness of including obesity as a determinant to restrict access to surgery. They described short-term financial pressures underlying the use of restrictive body mass index thresholds and a lack of an evidence base, such that policies amounted to rationing and risked exacerbations of health inequalities. The study identified four priorities for improvements to future health optimisation practices: developing and implementing national guidance with flexibility for local variation, initiating patient engagement in primary care with onward integration across all services, improving resourcing to support effective equitable impact, and addressing wider determinants of obesity through societal change.ConclusionsOverall, participants had limited expectations of the impact of health optimisation policies on obesity without additional support, investment, and national guideline implementation. They raised strong concerns over current restrictive approaches. We conclude that addressing concerns around weight management support service availability and impacts on health inequalities is essential for shaping effective health optimisation policies. Future policy direction should support health optimisation to be offered early (ideally in primary care). Health optimisation interventions should be non-restrictive, inclusive, and well-monitored, particularly around equality impact.

Molecular characterization of reassortant infectious bursal disease virus (IBDV) strains of genogroup A3B1 detected in some areas of Britain between 2020 and 2021

Infectious bursal disease virus (IBDV) causes a major immunosuppressive disease of chickens. As part of ongoing epidemiological surveillance for IBDV, the hypervariable region (HVR) of the VP2 capsid gene encoded by segment A, and a region of the VP1 polymerase gene, encoded by segment B, were sequenced from 20 IBDV-positive bursal samples obtained in 2020 and 2021, from 16 commercial British broiler farms. Birds had received a live IBDV vaccine at 17–22 days of age, and samples were obtained at 25–55 days of age. Of the 16 farms, none contained very virulent (vv) strains, one contained a classical virulent strain, two contained vaccine strains, and five contained sequences of reassortant strains with a vv segment A and a non-vv segment B belonging to genogroup A3B1. In eight of the farms, we identified the sequences of both genogroup A3B1 reassortant strains and vaccine strains in the same samples. Therefore, the majority of the farms (13/16 (81%)) contained genogroup A3B1 reassortant viruses. Of the flocks containing reassortant strains, 5/13 (38%) had HVR mutations Q219L, G254D, D279N, and N280T, consistent with a recently described Western European clade, but the rest had other mutations or no mutations, demonstrating that multiple clades were present in the samples. Taken together, vv strains were not detected, but reassortant strains predominated in the farms, which belonged to different clades, and were frequently found together with vaccine strains.

‘There for me’: learning from young people about challenges and enablers to continuing education

ABSTRACT Young people’s perspectives are not always central to policy and practice in widening participation contexts. This article explores enablers and barriers to educational progression by considering factors that young people suggest influence how they envisage and act on their futures. The underpinning study asked students aged 12–23 in disadvantaged areas of northern England to think about their possible selves using creative methods to encourage dialogue, including an animation and board game co-designed with university students. The findings suggested that students’ perceptions of their own futures are influenced by their experiences of being categorised or labelled, both in and out of school, as well as the quality of their relationships with adults and peers. The authors discuss how these factors tended to shape the young people’s experiences of being at school, with a view to rethinking labelling and enabling participatory spaces that cultivate the intersecting relationships, influences, structures and self-belief that make a difference.

Attitudes towards being offered a choice of self-sampling or clinician sampling for cervical screening: A cross-sectional survey of women taking part in a clinical validation of HPV self-collection devices.

Primary human papillomavirus (HPV) testing in cervical screening offers the opportunity for women to be given a choice between HPV self-sampling and traditional clinician screening. This study assessed attitudes towards a choice and anticipated future preference among women who had collected a vaginal self-sample alongside their usual cervical screen. Thirty-eight general practices across five areas in England. Overall, 2323 women (24-65 years; response rate: 48%) completed a survey after collecting a self-sample and having a clinician screen at their GP practice. We asked which test they preferred and assessed attitudes to being offered a choice. We explored age, education, ethnicity and screening experience as predictors of attitudes towards a choice and anticipated future choice. Most participants felt they would like a choice between self-sampling and clinician screening (85%) and thought this would improve screening for them (72%). However, 23% felt it would be difficult to choose, 15% would worry about making a choice, and nearly half would prefer a recommendation (48%). Compared with women with degree-level education, those with fewer qualifications were more likely to say they would worry about having a choice or would not want a choice (p < 0.001). The majority said they would choose to self-sample at home if offered a choice in the future (69%; n = 1602/2320). Self-sampling is likely to be popular, but offering a choice could cause worry for some people and many would prefer a recommendation. Supporting people to make a choice will be important, particularly for those with lower levels of education.

Variation in attendance at emergency departments in England across local areas: A system under unequal pressure

BackgroundCrowding in Accident and Emergency Departments (AEDs) and long waiting times are critical issues contributing to adverse patient outcomes and system inefficiencies. These challenges are exacerbated by varying levels of AED attendance across different local areas, which may reflect underlying disparities in primary care provision and population characteristics. MethodWe used regression analysis to determine how much variation across local areas in England of attendance at emergency departments remained after controlling for population risk factors and alternative urgent care provision. FindingsThere is substantial residual variation of the order of 3 to 1 (highest to lowest) in per person attendance rate across different areas. This is not related to in-hospital capacity as proxied by the per person number of hospital emergency doctors in an area. ConclusionSome areas in England have emergency departments that are under much greater pressure than others, and this cannot be explained in terms of their population characteristics or the availability of alternative treatment options. It is imperative to better understand the drivers of this variation so that effective interventions to address utilisation can be designed.

Predicting pharmaceutical concentrations and assessing risks in the aquatic environment using PERK: A case study of a catchment area in South-West England

The aim of this study was to introduce a model to predict pharmaceuticals concentrations in the aquatic environment and their environmental impacts using the Risk Quotient (RQ) approach. The model was trained using: (i) high resolution dataset on pharmaceuticals’ concentration in wastewater and receiving environment in a river catchment, (ii) understanding of pharmaceuticals’ discharge points in the catchment, (iii) fate of pharmaceuticals during wastewater treatment and in the receiving environment, (iv) high resolution per-postcode pharmaceutical prescription data. A total of 41 pharmaceuticals were evaluated, with successful predictions achieved for concentrations falling within the range of 0.7 (influent: 37 %, effluent: 39 %, river: 29 %) to 1 % (influent: 56 %, effluent: 58 %, river: 48 %) of the measured values. Importantly, our risk assessment demonstrates significant environmental risks associated with specific pharmaceuticals, with strong alignment (86 %) between assessments based on predicted and measured data, underscoring the reliability of our model in assessing environmental risks. The observed variability in predicted and measured concentrations underscores the necessity for ongoing model refinement, particularly in regions with notable discrepancies such as wastewater treatment plant (WWTP) C. Overall, our study illustrates the intricate dynamics of pharmaceutical contamination in aquatic ecosystems, emphasizing the crucial need for continued research in this field.

Syndemic Geographic Patterns of Cancer Risk in a Health-Deprived Area of England

ObjectivesThis study aims to analyse the geographical co-occurrence of cancers and their individual and shared risk factors in a highly deprived area of the North West of England to aid the identification of potential interventions. Study DesignAn ecological study design was employed and applied at postcode sector level. MethodsA novel spatial joint modelling framework designed to account for large frequencies of left-censored cancer data was employed. Nine cancer types (breast, colorectal, gynaecology, haematology, head and neck, lung, skin, upper gastrointestinal, urology) alongside demographic, behavioural factors and socio-economic variables were included in the model. Explanatory factors were selected by employing an accelerated failure model with lognormal distribution. Post-processing included principal components analysis and hierarchical clustering to delineate geographic areas with similar spatial risk patterns of different cancer types. Results15,506 cancers were diagnosed from 2017 to 2022, with the highest incidence in skin, breast and urology cancers. Factors such as age, ethnicity, frailty and comorbidities were associated with cancer risk for most of the cancer types. A positive geographical association was found mostly between the colorectal, haematology, upper GI, urology and head and neck cancer types. That is, these cancers had their largest risk in the same areas, similarly to their lowest risk values. The spatial distribution of the risk and cumulative risk of the cancer types revealed regional variations, with five clusters identified based on cancer type risk, demographic and socio-economic characteristics. Rural areas were the least affected by cancer and the urban area of Barrow-in-Furness was the area with the highest cancer risk, three times greater than the risk in the surrounding rural areas. ConclusionsThis study emphasizes the utility of joint disease mapping by geographically identifying common or shared factors that, if targeted, could lead to reduced risk of multiple cancers simultaneously. The findings suggest the need for tailored public health interventions, considering specific risk factors and socio-economic disparities. Policymakers can utilize the spatial patterns identified to allocate resources effectively and implement targeted cancer prevention programmes.

Social, behavioral and clinical risk factors are associated with clonal hematopoiesis.

Risk factors including smoking, alcohol intake, physical activity (PA), and sleep patterns have been associated with cancer risk. Clonal hematopoiesis (CH), including mosaic chromosomal alterations (mCAs) and clonal hematopoiesis of indeterminate potential (CHIP), is linked to increased hematopoietic cancer risk, and could be used as common pre-clinical intermediates for better understanding associations of risk factors with rare hematologic malignancies. We analyzed cross-sectional data from 478,513 UK Biobank participants without hematologic malignancies using multivariable adjusted analyses to assess the associations between lifestyle factors and CH types. Smoking was reinforced as a potent modifiable risk factor for multiple CH types, with dose-dependent relationships persisting post-cessation. Males in socially deprived areas of England had lower risk of mosaic loss of chromosome Y (mLOY), females with moderate/high alcohol consumption (2-3 drinks/day) had increased mLOX risk (OR=1.17, 95%CI:[1.09-1.25], p=8.31×10-6) compared to light drinkers, active males (moderate-high PA) had elevated risks of mLOY (PA Category 3: OR=1.06, 95%CI:[1.03-1.08], p=7.57×10-6) and men with high BMI (≥40) had reduced risk of mLOY (OR=0.57, 95%CI:[0.51-0.65], p=3.30×10-20). Sensitivity analyses with BMI adjustment attenuated the effect in the mLOY-PA associations (IPAQ2: OR=1.03, 95%CI:[1.00-1.06], p=2.13×10-2 and IPAQ3: OR=1.03, 95%CI:[1.01-1.06], p=7.77×10-3). Our study reveals associations between social deprivation, smoking, alcohol consumption, and CH risk, suggesting these exposures could contribute to common types of CH and potentially rare hematologic cancers. This study underscores the impact of lifestyle factors on CH frequency, emphasizing social, behavioral, and clinical influences and the importance of socio-behavioral contexts when investigating CH risk factors.

Effect modification of air pollution on the association between heat and mortality in five European countries

BackgroundEvidence suggests that air pollution modifies the association between heat and mortality. However, most studies have been conducted in cities without rural data. This time-series study examined potential effect modification of particulate matter (PM) and ozone (O3) on heat-related mortality using small-area data from five European countries, and explored the influence of area characteristics. MethodsWe obtained daily non-accidental death counts from both urban and rural areas in Norway, England and Wales, Germany, Italy, and the Attica region of Greece during the warm season (2000–2018). Daily mean temperatures and air pollutant concentrations were estimated by spatial-temporal models. Heat effect modification by air pollution was assessed in each small area by over-dispersed Poisson regression models with a tensor smoother between temperature and air pollution. We extracted temperature-mortality relationships at the 5th (low), 50th (medium), and 95th (high) percentiles of pollutant distributions. At each air pollution level, we estimated heat-related mortality for a temperature increase from the 75th to the 99th percentile. We applied random-effects meta-analysis to derive the country-specific and overall associations, and mixed-effects meta-regression to examine the influence of urban-rural and coastal typologies and greenness on the heat effect modification by air pollution. ResultsHeat-related mortality risks increased with higher PM levels, rising by 6.4% (95% CI: −2.0%–15.7%), 10.7% (2.6%–19.5%), and 14.1% (4.4%–24.6%) at low, medium, and high PM levels, respectively. This effect modification was consistent in urban and rural regions but more pronounced in non-coastal regions. In addition, heat-mortality associations were slightly stronger at high O3 levels, particularly in regions with low greenness. ConclusionOur analyses of both urban and rural data indicate that air pollution may intensify heat-related mortality, particularly in non-coastal and less green regions. The synergistic effect of heat and air pollution implies a potential pathway of reducing heat-related health impacts by improving air quality.

Projecting patterns of health inequalities in England up to 2040 using linked health data

ObjectiveThe existence of wide inequalities in self-reported health across England is well-documented. Our research adds to this evidence by describing current patterns and projecting future patterns of inequality in diagnosed illness by deprivation. ApproachWe used a microsimulation model which combines individual-level data on demographics, health and mortality from linked data for primary and secondary care with survey responses on leading modifiable risk factors and epidemiological evidence on the associations between risk factors and chronic illness. We used the Cambridge Multimorbidity Score to measure multimorbidity. This assigns a weight to 20 common long-term conditions based on individuals’ healthcare use and their likelihood of death. We further focus on “major illness” which corresponds to a score greater than 1.5. ResultsWe project that health inequalities are not projected to improve between 2019 and 2040. In 2040, we project the difference in the average time spent without major illness between the most and least deprived 10% of areas in England to be 10.7 years. This is largely unchanged from 10.4 years in 2019. In 2040, we project there will be more working age adults living with major illness in the most deprived areas, more than double the rate in the least deprived areas (15.2% versus 6.8%). These rates remain largely unchanged from 2019 at 14.6% and 6.3% respectively. Conclusion and ImplicationsOn current trends, health inequalities are projected to persist into the future. This has significant implications not just for population health but for labour supply and wider economic growth.

The development of a capability wellbeing measure in economic evaluation for children and young people aged 11-15

The capability approach provides a broad evaluative space for making funding decisions for health and care interventions, with capability wellbeing as the outcome of value. A range of capability measures have been developed for the economic evaluation of health and care interventions for adults. However, such measures have not been previously developed for children and young people for this purpose and may be valuable. This study aimed to identify important capabilities for children and young people aged 11–15, and to develop these into attributes for an economic measure that can inform funding decisions. Thirty-three qualitative in-depth interviews were undertaken with children and young people aged 11–15 (n = 19) and parents (n = 14) in urban and rural areas of England between September 2019 and November 2021. Purposeful maximum variation sampling ensured representation from different backgrounds. Children and young people were asked to think of things important to them and place these on sticky notes around a drawing/photograph of themselves; the interview asked them about these important things. Parents were asked to identify factors that enhanced and negatively impacted their child's quality of life. Analysis using constant comparison facilitated exploration of similarities and differences in important capabilities. A second phase of semi-structured interviews with children and young people (n = 15) explored how these attributes should be expressed in a meaningful way. Eight overarching capability wellbeing themes were identified, with some variation across children and young people, and parent groups: Fun and enjoyment; Learning and experiencing; Attachment; Emotional security andsupport; Achievement; Identity and choice; Physical safety; Aspiration. Potentially, this information will help to provide an alternative approach to the measurement of benefits to children and young people for economic evaluation of health and care interventions, one that will be better able to capture benefits associated with interventions to improve the social determinants of health.

How does online postal self-sampling (OPSS) shape access to testing for sexually transmitted infections (STIs)? A qualitative study of service users

BackgroundSexually transmitted infections (STIs) are a serious public health issue in many countries. Online postal self-sampling (OPSS) is increasingly used to test for STIs, a trend accelerated by the COVID-19 pandemic. There remains limited understanding of how service users experience OPSS and what leads them to access it over clinic-based services, or vice versa. This research seeks to address these gaps, by undertaking a large qualitative study which sits within the ASSIST study, a mixed-methods, realist evaluation of OPSS.MethodsParticipants were recruited via clinic-based and online sexual health services in three case study areas in England. Purposive sampling was used to over-represent populations disproportionately affected by poor sexual health: young people; people of colour; men who have sex with men; and trans and non-binary people. Semi-structured interviews were analysed using Levesque’s conceptual framework of access to healthcare.ResultsWe interviewed 100 service users. Participants typically became aware of OPSS from sexual health services, the internet or word of mouth. Acceptability of OPSS was facilitated by the perceived privacy it offered over clinic-based services, which some participants found embarrassing to access. OPSS also enabled participants to overcome barriers to reaching clinic-based services, such as a lack of appointment availability, although difficulty obtaining OPSS kits in some areas undermined this. As all services in our case study areas were free to use, affordability did not significantly shape access, although OPSS enabled some participants to avoid costs associated with travelling to clinic-based services. Participants were usually able to engage with OPSS, finding it easy to use and reliable, although blood self-sampling was challenging for most. Participants valued the support offered by clinic-based services beyond STI testing, including the opportunity to access contraception or ask staff questions, and felt this was more appropriate when they had specific concerns about their sexual health, such as STI symptoms.ConclusionsOur findings constitute one of the largest qualitative studies to have explored OPSS and offer valuable insights to providers. OPSS shapes access to STI testing in a number of ways, including facilitating access in many circumstances, but users also want to retain access to clinic-based services, particularly for when they believe they need support beyond STI testing.

Area-level factors associated with variation in involuntary psychiatric hospitalisation across England: a cross-sectional, ecological study.

Involuntary hospitalisations for mental health care are rising in many high income countries, including England. Looking at variation between areas can help us understand why rates are rising and how this might be reversed. This cross-sectional, ecological study aimed to better understand variation in involuntary hospitalisations across England. The unit of analysis was Clinical Commissioning Groups (CCGs), NHS bodies responsible for delivering healthcare to local areas in England. 205 CCGs were included in the analysis. Demographic, clinical, and socioeconomic variables at CCG-level were extracted from national, open access data bases. The outcome variable was the rate of involuntary hospitalisation for psychiatric care under the 1983 Mental Health Act in 2021/22. There was a four-fold difference between the CCGs with the highest and lowest involuntary hospitalisations. In an adjusted analysis, CCGs with a higher percentage of severe mental illness in the population, higher percentage of male population, and higher community and outpatient mental health care use showed a higher rate of involuntary hospitalisation. Depression, urbanicity, deprivation, ethnicity, and age were not strongly associated with involuntary hospitalisation after adjustment. These variables explained 10.68% of the variation in involuntary hospitalisations across CCGs. Some demographic and clinical variables explained variation in involuntary hospitalisation between areas in England, however, most of the variance was unexplained. Complex relationships between urbanicity, deprivation, age, and ethnicity need to be further explored. The role of other influences, such as variation in service organisation or clinical practice, also need to be better understood.

Young people's views and experience of diet-related inequalities in England (UK): a qualitative study.

Inequalities in diets contribute to overall inequalities in health. Economic inequality and inequalities in access to healthy food are key drivers of poor diet and ill health among young people (YP). Despite mounting evidence of structural barriers to healthy eating, less is known about how YP view and experience these inequalities where they live, and how to address them. To explore YP's perspectives on the drivers of diet-related health inequalities, we conducted three interlinked focus groups with YP aged 13-21 years from six youth groups across three geographical areas in England. We analysed the data inductively and deductively using reflexive thematic analysis and generated themes by examining how social structure, context and agency interact and impact YP's diet. YP were aware of how inequalities in employment conditions impact their families' income and ability to eat a healthy diet. They cited the high availability of hot food takeaways in their local areas as a significant barrier to healthy eating but did not support closing or restricting these outlets. They held strong views on policies to tackle diet inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Our study showed that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities. However, further efforts are needed to shape and promote policies that resonate with YP and address both their health and wider social concerns.

Looking at the future of the medical certification of cause of death (MCCD) in England and Wales.

Internationally, the quality of death certification is poor although there are multiple efforts underway to improve the process. In England, a new medical certification system has been proposed to improve the quality of data. We surveyed general practitioners (n = 95) across the West Yorkshire area of England to appraise their views regarding whether further possible changes to the death certification system could promote their quality.

Epigenetic age acceleration in follicular fluid and markers of ovarian response among women undergoing IVF.

Are markers of epigenetic age acceleration in follicular fluid associated with outcomes of ovarian stimulation? Increased epigenetic age acceleration of follicular fluid using the Horvath clock, but not other epigenetic clocks (GrimAge and Granulosa Cell), was associated with lower peak estradiol levels and decreased number of total and mature oocytes. In granulosa cells, there are inconsistent findings between epigenetic age acceleration and ovarian response outcomes. Our study included 61 women undergoing IVF at an academic fertility clinic in the New England area who were part of the Environment and Reproductive Health Study (2006-2016). Participants provided a follicular fluid sample during oocyte retrieval. DNA methylation of follicular fluid was assessed using a genome-wide methylation screening tool. Three established epigenetic clocks (Horvath, GrimAge, and Granulosa Cell) were used to predict DNA-methylation-based epigenetic age. To calculate the age acceleration, we regressed epigenetic age on chronological age and extracted the residuals. The association between epigenetic age acceleration and ovarian response outcomes (peak estradiol levels, follicle stimulation hormone, number of total, and mature oocytes) was assessed using linear and Poisson regression adjusted for chronological age, three surrogate variables (to account for cellular heterogeneity), race, smoking status, initial infertility diagnosis, and stimulation protocol. Compared to the median chronological age of our participants (34 years), the Horvath clock predicted, on an average, a younger epigenetic age (median: 24.2 years) while the GrimAge (median: 38.6 years) and Granulosa Cell (median: 39.0 years) clocks predicted, on an average, an older epigenetic age. Age acceleration based on the Horvath clock was associated with lower peak estradiol levels (-819.4 unit decrease in peak estradiol levels per standard deviation increase; 95% CI: -1265.7, -373.1) and fewer total (% change in total oocytes retrieved per standard deviation increase: -21.8%; 95% CI: -37.1%, -2.8%) and mature oocytes retrieved (% change in mature oocytes retrieved per standard deviation increase: -23.8%; 95% CI: -39.9%, -3.4%). The age acceleration based on the two other epigenetic clocks was not associated with markers of ovarian response. Our sample size was small and we did not specifically isolate granulosa cells from follicular fluid samples so our samples could have included mixed cell types. Our results highlight that certain epigenetic clocks may be predictive of ovarian stimulation outcomes when applied to follicular fluid; however, the inconsistent findings for specific clocks across studies indicate a need for further research to better understand the clinical utility of epigenetic clocks to improve IVF treatment. The study was supported by grants ES009718, ES022955, ES000002, and ES026648 from the National Institute of Environmental Health Sciences (NIEHS) and a pilot grant from the NIEHS-funded HERCULES Center at Emory University (P30 ES019776). RBH was supported by the Emory University NIH Training Grant (T32-ES012870). N/A.